The Medicaid trick: It’s not about insurance

New Hampshire’s Medicaid Expansion Commission is scheduled to make its final recommendations to legislators tomorrow. Gov. Maggie Hassan is expected to call the Legislature into a special session to act on the recommendation, which will be to expand eligibility. That would be a mistake for reasons that should be obvious.

If the point of expanding Medicaid eligibility from 63 percent of the federal poverty level to 138 percent is to provide health insurance to more Granite Staters, there are far better ways to do that. But is that the point?

The Llewin Group study commissioned by the state Department of Health and Human Services provides some insight. It estimated that 58,000 people would enroll in Medicaid under expansion. In the absence of expansion, only 38 percent (22,000) would remain uninsured, 20 percent would find insurance through the Obamcare exchange, and 35 percent would “remain under private coverage.” Seven percent would enroll in Medicaid under current eligibility guidelines.

If New Hampshire expands Medicaid eligibility under the terms imposed by the Obama administration (the state must expand to 138 percent or not expand at all), fully 55 percent of new enrollees (32,000 people) would choose government-funded Medicaid instead of private insurance they otherwise would buy. This is not a plan to insure the desperately poor. It is a plan to make tens of thousands of Granite Staters dependent upon Washington for their health insurance.

To assist in this scheme would cost New Hampshire $85 million through 2020 alone, the study found. Expansion supporters say expansion is “free” because Congress has promised to pay 90 percent of the state’s costs. If we expand, we would be betting the New Hampshire Advantage on a promise from Congress (see the column by Cottage Hospital CEO Maria Ryan on the opposite page).

New Hampshire already offers subsidized health insurance premiums to low-income families (as does Vermont). This is a far better and less costly way to provide a health insurance safety net. Last week the commission recommended expanding eligibility and putting some people into this program instead of Medicaid. But that requires a federal waiver. What if it is not granted?

New Hampshire should not expand under the terms imposed by the administration. But if it does, legislators should insist on no expansion without 1) a waiver allowing us to substitute premium support for expanded Medicaid, 2) an escape clause allowing the state to drop the expansion if the federal share of the costs falls below the promised percentage, and 3) a requirement that anyone eligible for both subsidies and non-subsidized coverage (such as an employer’s or a parent’s plan) take the non-subsidized option.